$300 per day for days 1–5 of your stay. Thereafter, no charge for the remainder of your stay.

$225 / $215 per day for days 1–7 of your stay. Thereafter, no charge for the remainder of your stay.

Outpatient Surgery

$245

$190

Skilled Nursing Facility

Up to 100 days per benefit period

$0 per day for days 1–20

$156 per day for days 21–100

$0 per day for days 1–20

$125 per day for days 21–100

Lab, X-Ray, Imaging

$0–$50 Lab, $25–$50 X-Ray, $220–$280 MRI, PET, CT scans

$0–$50 Lab, $15–$50 X-Ray, $130–$225 MRI, PET, CT scans

Durable Medical Equipment

20% coinsurance

20% coinsurance

Ambulance Service

Per one-way trip

$250 copay

$250 copay

Fitness Program:

SilverSneakers®

No cost for membership to any of the participating facilities, exercise programs, and home fitness programs.

No cost for membership to any of the participating facilities, exercise programs, and home fitness programs.

For more information about benefits, please view the 2015 Summary of Benefits.

These plans include Medicare Part D prescription drug coverage. Copay and coinsurance amounts below are for up to a month’s supply. You can save on most refills of a 3-month supply through our mail order pharmacy and have them mailed to your home at no extra charge.

Premiums and Benefits

Kaiser Permanente Senior Advantage Basic(HMO)

Kaiser Permanente Senior Advantage Enhanced (HMO)

Part D Prescription Drug Coverage

DESCRIPTION

YOU PAY

YOU PAY

Initial Coverage Stage

(for up to a 30-day supply from an in-network pharmacy with preferred cost sharing)

When the total drug costs paid by you and any Part D plan reach $2,960, you move into the Coverage Gap Stage.

$7 preferred generic

$10 nonpreferred generic

$44 preferred brand-name

$95 nonpreferred brand-name

33% coinsurance for specialty

$0 injectable Part D vaccines

$5 preferred generic

$10 nonpreferred generic

$44 preferred brand-name

$80 nonpreferred brand-name

33% coinsurance for specialty

$0 injectable Part D vaccines

Coverage Gap Stage

(for up to a 30-day supply from an in-network pharmacy with preferred cost sharing)

You pay 45% for brand-name & specialty drugs (including a portion of the dispensing fee)

$0 injectable Part D vaccines

$5 preferred generic

$10 nonpreferred generic

You pay 45% for brand-name & specialty drugs (including a portion of the dispensing fee)

$0 injectable Part D vaccines

Catastrophic Coverage Stage

When your annual out-of-pocket costs exceed $4,700, you pay lower cost shares for the remainder of the calendar year.

$5 generic

$15 brand-name & specialty

$0 injectable Part D vaccines

$2 generic

$10 brand-name & specialty

$0 injectable Part D vaccines

Our Mail-Order Pharmacy3

(Restrictions & limitations may apply)

$0 copay for up to a 90-day supply for preferred generic drugs. Two copays for up to a 90-day supply for all other covered drugs.

$0 copay for up to a 90-day supply for preferred generic drugs. Two copays for up to a 90-day supply for all other covered drugs.

1You must continue to pay your Medicare Part B premium and any other applicable Medicare premium(s), if not otherwise paid by Medicaid or another third party.2$0 copay for all preventive services covered under Original Medicare at zero cost sharing.3For certain drugs, you can get prescription refills mailed to you through our Kaiser Permanente mail-order pharmacy. You should receive them within 10 business days. If not, please call 1-888-218-6245 (TTY 711), Monday through Friday, 8 a.m. to 6 p.m.

Note: If you have health care coverage through an employer or trust fund, please contact your benefits administrator for information about your group plan.

* Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next. Centers for Medicare & Medicaid Services Health Plan Management System, Plan Ratings 2015. Kaiser Permanente contract #H1170.

Note: Our Kaiser Permanente Senior Advantage Medicare Medicaid Plan is available to individual plan members only. If you are a member of a Kaiser Permanente plan through your employer or union and are interested in this plan, call us to find out how to qualify.

Anyone who has Medicaid and Medicare Parts A and B, including some people under the age of 65 with disabilities, may apply.

Premiums, copays, coinsurance/cost sharing, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

Kaiser Permanente is an HMO SNP plan with a Medicare contract and a contract with the state Medicaid program. Enrollment in Kaiser Permanente depends on contract renewal.

Healthways SilverSneakers® Fitness program

Exercise is good for you — at any age. The SilverSneakers Fitness program is designed specifically to help you achieve better health through regular exercise and social activities with people who share your interest in healthy living. SilverSneakers includes the following benefits at no cost beyond your plan premium:

a basic fitness membership with access to more than 11,000 participating fitness locations across the nation

SilverSneakers® classes designed to improve strength, flexibility, and balance, taught by certified instructors

Program AdvisorsSM to provide guidance and support

fun social activities

access to the SilverSneakers members-only website with a wide range of tools and resources

SilverSneakers® Steps for those without convenient access to SilverSneakers fitness locations

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply.

You must continue to pay your Medicare Part B premium and any other applicable Medicare premium(s), if not otherwise paid by Medicaid or another third party.

Our Medicare Part D drug formulary is a list of the prescription drugs that are approved for coverage by Kaiser Permanente's Medicare health plan. Learn more about our Part D drug formulary below.

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2015 Kaiser Permanente Medicare Part D formulary

The Kaiser Permanente comprehensive formulary is a list of covered Part D drugs representing the prescription therapies believed to be a necessary part of a quality treatment program. The formulary is selected in consultation with a team of Kaiser Permanente health care providers. Our formulary includes all drugs that can be covered under Medicare Part D according to Medicare requirements.

After downloading the formulary, there are several ways to find your Part D drug and the tier level it is in.

Medical condition. If you know the condition treated by your drug, you can look under category name. For example, drugs used to treat a heart condition are listed under “Cardiovascular Drugs.”

Alphabetical listing. If you are not sure of the category, look in the index, which provides an alphabetical list of all brand-name and generic drugs in the formulary.

Search. Use Control + “F” (hold down the Control and “F” keys) to call up the search box. Type in the name of your drug and press “Enter” to be taken to its listing in the formulary.

Our plan will generally cover any drug listed on our formulary as long as:

the drug is medically necessary

the prescription is filled at a Kaiser Permanente or affiliated pharmacy

other plan rules are followed

We cover both brand-name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

Generally, the cost sharing you will pay for your drugs depends on your coverage stage, the type of pharmacy where you purchase your drugs, and your drug’s cost-sharing tier on our formulary. Please refer to your Annual Notice of Changes/Evidence of Coverage for the details about your Medicare Part D prescription drug coverage, including your cost-sharing amounts.

If you are in an employer-sponsored group plan, your Part D benefits and coverage may be different. You should check your group Evidence of Coverage or other plan materials for details.

For information on how to fill your prescriptions, please review your Annual Notice of Changes/Evidence of Coverage.

Changes to the formulary

Kaiser Permanente may add or remove drugs from the formulary during the year. The formulary on this page is the most current.

Generally, if you are taking a drug that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or if we receive information from the FDA that a drug is no longer safe or effective.

Other types of formulary changes, such as removing a drug, will not affect members currently taking the drug. The drug will remain available at the same cost for the remainder of the coverage year.

We will notify members affected by changes at least 60 days before the date that the change becomes effective, or at the time the member requests a refill of the drug (at which time the member will receive a 60-day supply of the drug). Examples of changes include the following:

If the FDA deems a drug on our formulary to be unsafe, or if the drug's manufacturer removes the drug from the market, we immediately will remove the drug from our formulary and notify members who take the drug.

We also will notify you of formulary changes through the Provision of Notice (coming soon) or Explanation of Benefits, which will detail all your pharmacy transactions and annual accumulations.

For current information about the drugs covered by Kaiser Permanente, contact us seven days a week, 8 a.m. to 8 p.m. at:

1-800-232-4404 (toll free)TTY 711

Getting an exception to the formulary

If there are certain restrictions or limitations on a Part D drug, you can:

Ask your Kaiser Permanente or affiliated provider to prescribe a similar drug that is included on our formulary.

Ask us to waive coverage restrictions such as a prior authorization on your Part D drug.

Ask us to cover a Part D formulary drug at a lower cost-sharing level if this drug is not on the specialty tier (Tier 5), subject to our tiering exception process. If approved, this would lower the amount you may pay for your drug.

Generally we will only approve your request for an exception if the alternative drugs included on our formulary, the lower-tiered drug, or additional utilization restrictions would not be as effective in treating your condition or would cause you to have adverse medical effects.

When you are requesting a utilization restriction or tiering exception, you or your Kaiser Permanente or affiliated provider should submit a physician statement supporting your request.

Generally, we must make our decision within 72 hours of getting your request for a coverage decision as long as we have your prescribing physician's supporting statement.

You can request an expedited (fast) exception if you or your Kaiser Permanente or affiliated provider believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician's supporting statement.

Note: You can request an exception only for drugs that are considered Medicare Part D prescription drugs by the Centers for Medicare & Medicaid Services (CMS). You cannot get an exception for drugs that are excluded under Medicare Part D or for obtaining a brand-name drug (Tier 3) at the cost sharing that applies to generic drugs.

Please refer to your Annual Notice of Changes/Evidence of Coverage for more information about requesting exceptions, including the appeals process.

If your Kaiser Permanente or affiliated provider does not grant a utilization or tiering exception, you may request a coverage determination, which is an initial decision we make about whether we will cover a Medicare Part D drug and the amount you are required to pay.

For complete information on how to request a coverage determination, please refer to the Annual Notice of Changes/Evidence of Coverage or go to our section on grievances, coverage determinations, and appeals.

Kaiser Permanente’s Transition Process for Medications

In rare cases, you might be taking Medicare Part D drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it may be limited. For example, you may need a prior authorization from us before you can fill your prescription.

If this is the case, you should talk to your Kaiser Permanente or affiliated provider about switching to an appropriate drug that we cover. Your Kaiser Permanente or affiliated provider also may request a utilization or tiering exception for the drug you take. We may cover your drug in certain cases during the first 90 days you are a new member of our plan.

If your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a Kaiser Permanente or affiliated pharmacy. After your first 30-day supply, we may cover an additional refill, as medically necessary. After you have used these refills, we will not pay for these drugs.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with up to a 98-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer days). We will cover more than 1 refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary, or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, then we will cover a 31-day emergency supply of that drug (unless you have a prescription written for fewer days) while you pursue an exception.

If, as a current member of our plan, you have a covered inpatient stay in the hospital or in a skilled nursing facility, then drugs you obtain during your stay will be covered under your medical benefit rather than your Medicare Part D prescription drug coverage. When you are discharged home or to a custodial level of care at a long-term care facility, many outpatient prescription drugs you obtain at a pharmacy will be covered under your Medicare Part D coverage.

Because coverage is different depending on where you obtain the drug, it is possible that a drug covered under your medical benefit might not be covered by Medicare Part D (for example, over-the-counter drugs, or cough medicine). If this happens, you will have to pay full price for that drug unless you have other coverage (for example, employer-sponsored group coverage).

Please refer to your Annual Notice of Changes/Evidence of Coverage for more information about our transition policy and drugs not covered by Medicare Part D.

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Kaiser Permanente and affiliated pharmacies

You must use a Kaiser Permanente or affiliated pharmacy to get your prescription drug benefit except in limited, non-routine circumstances. Generally, you may find a pharmacy at the Kaiser Permanente medical office or center where you see your primary care provider or specialist. However, you can fill or refill a prescription at any Kaiser Permanente preferred cost-sharing pharmacy or our mail-order pharmacy, which has lower pricing than an affiliated standard cost-sharing pharmacy.

We operate our own pharmacies and contract with affiliated pharmacies that equal or exceed CMS requirements for pharmacy access in your area. The Kaiser Permanente pharmacy network has several pharmacies in the Georgia region.

To fill your prescription at a Kaiser Permanente or affiliated pharmacy, you must show your Kaiser Permanente Senior Advantage (HMO) Member ID card and photo identification to receive it at your Medicare Part D cost share. If you do not have your ID card with you when you fill your prescription, or if you receive a prescription from a non-Plan, non-affiliated provider in conjunction with covered emergency care or out-of-area urgent care, then you may have to pay the full cost of the prescription.

If this happens, you can ask us to reimburse you for our share of the cost by submitting a paper claim to us. To find out how to submit a claim, see your Annual Notice of Changes/Evidence of Coverage.

You will receive a statement by mail called the Explanation of Benefits (EOB) for any month you use your Medicare Part D benefits. (See an example of the EOB and find out more about how to receive your EOB electronically.) The EOB will list all Medicare Part D transactions from the previous month and display what you've spent (total out-of-pocket expenses) and what your total drug costs are year-to-date. If there are formulary changes within a 60-day period, we will notify you by mail through a Provision of Notice or your Explanation of Benefits.

Out-of-network pharmacy coverage

Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a Kaiser Permanente or affiliated pharmacy is not available.

For example, if you are traveling within the United States and its territories but outside the service area and you become ill or run out of your covered drugs, we will cover prescriptions filled at an out-of-network pharmacy in limited circumstances according to our Part D formulary guidelines.

If you need a Medicare Part D prescription drug in conjunction with covered out-of-network emergency care or out-of-area urgent care, we will cover up to a 30-day supply from an out-of-network pharmacy.

Note: Prescription drugs prescribed and provided outside of the United States and its territories as part of covered emergency or urgent care are covered up to a 30-day supply in a 30-day period. These drugs are not covered under Medicare Part D; therefore, payments for these drugs do not count toward reaching the catastrophic coverage stage.

We also will cover Medicare Part D drugs on our formulary that you obtain at an out-of-network pharmacy if one or both of the following applies:

You are unable to obtain a covered drug in a timely manner within our service area because there is no Kaiser Permanente or affiliated pharmacy within a reasonable driving distance that provides 24-hour service. We may not cover your prescription if a reasonable person could have purchased the drug at a Kaiser Permanente or affiliated pharmacy during normal business hours.

You are trying to fill a prescription for a drug not regularly stocked at an accessible Kaiser Permanente or affiliated pharmacy or available through our mail-order pharmacy (including high-cost drugs).

In these situations, you will have to pay the full cost (rather than paying just your Medicare Part D cost share) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim.

For complete information about out-of-network pharmacy coverage or how to file a paper claim, please refer to your Annual Notice of Changes/Evidence of Coverage.

If you have not done so already, you'll need to register for a secure kp.org account in order to refill prescriptions online. You also can set up mail-order services when you visit your Kaiser Permanente pharmacy or call the number on the prescription label.

Most prescription refills can be mailed to your home at no extra charge or you may designate the Kaiser Permanente or affiliated pharmacy where you want to pick up and pay for your prescription.

Mail your prescription refill request on a mail-order form that is also available at any Kaiser Permanente pharmacy.

Mail-order services

When you order prescription refills by mail, there's no extra charge for postage and your costs may be lower for a 3-month supply. Please look in your Annual Notice of Changes/Evidence of Coverage for details.

Most covered Medicare Part D drugs can be refilled using our mail-order service, but there are some exceptions. Certain drugs that require special handling or packaging are not provided through our mail-order service, such as:

drugs that are time- or temperature-sensitive

drugs that we identify as unmailable

certain high-cost drugs

drugs that require professional administration or observation

Items available through our mail-order service are subject to change at any time without notice and may be subject to state and other licensing restrictions. Please check with your Kaiser Permanente or affiliated pharmacy or mail-order pharmacy if you have a question about whether or not your prescription can be mailed.

Note: Prescription drugs that you get through a mail-order service other than Kaiser Permanente are not covered.

Please allow up to 10 business days for delivery of your prescription by mail. If your mail-order prescription is delayed, please call Kaiser Permanente at 770-434-2008 or 1-888-662-4579 (toll free) or TTY 711, Monday through Friday, 8 a.m. to 5 p.m. or the number on your prescription label for assistance. If you have no refills left, it may take an additional 48 hours for us to contact your Kaiser Permanente or affiliated provider to confirm your prescription refill.

For more information about our mail-order services, please look in your Annual Notice of Changes/Evidence of Coverage.

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Medicare medication therapy management

Kaiser Permanente provides a medication therapy management (MTM) program for current Medicare Part D members who have multiple medical conditions for which they are taking a number of prescription drugs and meet an annual medication cost threshold.

The MTM program is not a benefit, but is an extra service offered at no additional cost to eligible members who qualify. This program has been developed for Kaiser Permanente by a team of pharmacists and doctors to help us provide better care for our members. Specially trained pharmacists will work with you and your doctor to ensure that the medications you take are necessary, safe, and effective. Our pharmacists will be able to help you over the phone.

Am I eligible for the MTM Program?

The 3 factors below will help determine if you are eligible for the MTM program:

1. If you have three (3) or more of the following medical conditions:

high cholesterol

high blood pressure

coronary artery disease

diabetes

stroke

rheumatoid arthritis

chronic obstructive pulmonary disease

osteoporosis

chronic noncancer pain

2. If you are taking five (5) or more of the following Part D medications:

drugs for high cholesterol (e.g. atorvastatin)

drugs for high blood pressure (e.g. lisinopril, hydrochlorothiazide)

drugs for diabetes (e.g. metformin, insulin)

drugs for rheumatoid arthritis (e.g. etanercept)

bronchodilators (e.g. albuterol)

inhaled corticosteroids (e.g. bethamethasone)

osteoporosis agents (e.g. alendronate)

3. You spend more than $3,138 per year on Part D medications.

You may complete this Personal Medication form♦ for your records and to share with your Kaiser Permanente or affiliated provider. Or we may contact you and ask you to complete one over the phone.

How will I know if I qualify?

You or your authorized representative will receive a letter describing our MTM program with a phone number to call to set up your Comprehensive Medication Review (CMR) with our pharmacist. You may also receive a follow-up reminder by phone or through an automated voice message system.

The majority of CMRs are conducted over the phone at your convenience, and take about 15 to 20 minutes. Depending on the identified need, a targeted medication review (TMR) may also be conducted over the phone that will take about 10 to 15 minutes.

Our staff will ask about your prescription medications as well as any over-the-counter medications, herbal and/or dietary supplements you may be taking. The pharmacist will review your medications and determine if there are any medication-related opportunities (such as reducing side effects, harmful drug interactions or lower drug costs). You will receive an individualized, written summary that includes a personal medication list and medication action plan that will help you get the most out of your medications.

Your current medications will be updated in our electronic medical record, which will be readily available and accessible to your doctor and others on your health care team.

We recommend that you take full advantage of this MTM service if you qualify. Remember, you don't need to pay anything extra to participate

Please review this MTM flyer♦, which can be mailed to you upon request, or contact Senior Advantage Member Services Department at (404) 233-3700 (toll free) (TTY 711) seven days a week, 8 a.m. to 8 p.m. for more details about qualifying for this free service.

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Extra help for Medicare Part D drugs

Are you a Kaiser Permanente Senior Advantage (HMO) member with limited income and resources?

People with limited incomes may qualify for extra help to pay for their prescription drug costs: the low-income subsidy, or LIS.

If eligible, Medicare could pay for some or most of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it.

We can help you find out if you are eligible. If you qualify, you may have lower monthly premiums for the prescription drug coverage under your Kaiser Permanente plan. You also may have lower cost sharing for your prescriptions. Visit our BenefitsCheckUp website† to see if you might be eligible for the LIS — and for other programs that can help you save money and cover everyday expenses.

Social Security at 1-800-772-1213 (toll free) between 7 a.m. and 7 p.m., Monday through Friday, or 1-800-325-0778 (toll-free TTY for the hearing/speech impaired). Or visit the Social Security website†.

your state Medicaid office

For general information about extra help, please call 1-800-MEDICARE (1-800-633-4227) (toll free), or 1-877-486-2048 (toll-free TTY for the hearing/speech impaired), 24 hours a day, 7 days a week. Or visit the Medicare website†.

You may also visit your Member Services Department located in most Kaiser Permanente medical facilities for assistance.

How much will I pay?

If you continue to qualify for the same level of help next year, then the table tells you how your prescription costs will change.

If you pay this much this year (2014)

You will pay this much next year (2015)

$0 deductible

$0 deductible

$63 deductible

$66 deductible

$1.20 for generics and brands that are treated as generics

$3.60 for brand-name drugs

$1.20 for generics and brands that are treated as generics

$3.60 for brand-name drugs

$2.55 for generics and brands that are treated as generics

$6.35 for brand-name drugs

$2.65 for generics and brands that are treated as generics

$6.60 for brand-name drugs

No more than 15% coinsurance for all drugs

No more than 15% coinsurance for all drugs

Note: If the copayment, coinsurance, or deductible amount listed in your “Evidence of Coverage Rider for Those Who Receive Extra Help Paying for Their Prescription Drugs” is less than the amount listed above, then you will pay the lower amount.

The amount of extra help you get will determine your total monthly plan premium and your prescription drug cost sharing as a member of the Kaiser Permanente Senior Advantage plan. For details, refer to the “Evidence of Coverage Rider for Those Who Receive Extra Help Paying for Their Prescription Drugs.”

You may get (or may have gotten) a letter from Medicare or Social Security about your 2015 eligibility for extra help. Read this information carefully. If you don’t know what level of extra help you qualify for, you can call 1-800-MEDICARE (1-800-633-4227) (toll-free), or 1-877-486-2048 (toll-free TTY for the hearing/speech impaired), 24 hours a day, 7 days a week.

You may ask whether you qualify for the Kaiser Permanente Senior Advantage Medicare Medicaid Plan (HMO SNP), which provides assistance with your health plan and Medicare Part D drug benefits, by calling Senior Advantage Member Service Department.

2015 LIS premium summary chart

The table below shows you what your monthly plan premium will be if you get extra help. (This does not include any Medicare Part B premium you may have to pay.) The monthly plan premiums listed include coverage for both medical services and prescription drug benefits. You must continue to pay your Medicare Part B premium and any other applicable Medicare premium(s), if not otherwise paid by Medicaid or another third party.

Monthy premiums

Your level of extra help

Senior Advantage Basic (HMO)

Senior Advantage Medicare Medicaid (HMO)

Senior Advantage Enhanced (HMO)

100%

$0.00

$0.00

$66.00

75%

$0.00

$6.50

$66.00

50%

$0.00

$13.00

$66.00

25%

$0.00

$19.50

$66.00

Best available evidence

If you think you are eligible for Medicare’s extra help and that you are not paying the correct monthly premium or costs for your drugs, you or your appointed representative may be able to correct your Medicare records by providing us with information, known as best available evidence (BAE), about your eligibility for extra help.

When we receive and verify your BAE, we will share it with Medicare and also update our records within 3 business days. You also will need to provide the information to a Kaiser Permanente or affiliated pharmacy when you obtain prescriptions so that we can charge you the appropriate cost-sharing amount until Medicare updates its records to reflect your current status.

Acceptable examples of BAE documents include copies of the following:

your state Medicaid card

your extra help Social Security award letter

Supplemental Security Income (SSI) Notice of Award with an effective date

a state document that confirms your active Medicaid status

other official state documentation showing your Medicaid status

a Home and Community-Based Services (HCBS) Notice that includes your name and HCBS eligibility date

For members who are institutionalized or in a long-term care facility, an appointed representative can provide a copy of the following BAE examples:

a remittance from the facility showing Medicaid payment for a full calendar month with that individual’s name on the statement

a copy of a state document that confirms Medicaid payment to the facility for a full calendar month on behalf of the individual

a screen printout from the state’s Medicaid information system showing that individual’s institutional status based on at least a full calendar month stay for Medicaid payment purposes

You or your appointed representative can mail a copy of your BAE document with your medical or health record number to:

If you have additional questions about BAE or need assistance if you don’t have documentation, please call Senior Advantage Member Services at 1-800-232-4404 (toll free) or TTY 711, from 8 a.m. to 8 p.m., 7 days a week. You also can visit the CMS Best Available Evidence page.†

We have policies and procedures that define standards for pharmacy practice as required by state and federal laws. They include:

drug utilization review systems designed to ensure that a review of your drug therapy is performed before each prescription is dispensed, to check for issues such as potential drug therapy problems, drug-drug interactions, and drug-allergy interactions

computerized drug utilization review systems designed to ensure ongoing periodic examination of prescription data and other records in order to identify drug therapy problems among Senior Advantage (HMO) members

For quality-of-care issues, an enrollee may file a grievance with Kaiser Permanente, a written complaint with the quality improvement organization (QIO), or both. The QIO review of a quality-of-care issue is separate and distinct from Kaiser Permanente’s Medicare Part D grievance procedures. You may file a complaint with the local QIO by writing to:

Kaiser Permanente may have requirements, restrictions, or limits on certain covered prescription drugs for coverage. These are developed by a team of doctors and pharmacists to control drug plan costs and to help ensure that our members use the drugs safely and in the most effective way.

This means that you may need to get prior authorization from us for certain drugs before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

Drugs needing prior authorization♦ may be covered under Medicare Part B or Part D or Medicare Part A or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. For example, prior authorization (PA) may apply to certain Part D drugs used in a hospice setting. Hospice providers may complete this form♦ if necessary. PA may also apply to drugs in which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered.

Our plan limits the quantity of certain drugs that will be covered. For example, we provide 14 pills per prescription for Sovaldi and charge one Part D cost share.

Note: For certain drugs, we may limit the amount of an extended day supply (amounts that exceed a one month supply) that you can receive. Also, if there is a shortage in the marketplace, we may charge 1 Part D cost share for a limited quantity.

You can find out if your drug is subject to these requirements or limits by looking in the Kaiser Permanente comprehensive formulary.

Reporting suspected fraud

We encourage our members, as well as our vendors and others, to let us know of any situation at Kaiser Permanente that may be unlawful. If we know about such a situation, we can investigate and take action to protect our members and our health care resources.

If you believe you’ve experienced fraud (or are aware of a fraud, waste, or abuse matter involving Kaiser Permanente members or resources), please contact Member Services.

You can also contact Medicare for fraud-related questions and concerns at:

We encourage you to let us know right away if you have questions, concerns, or problems related to your covered services or the care you receive by contacting Member Services at 1-800-232-4404 (toll free) or TTY 711, from 8 a.m. to 8 p.m., 7 days a week.

Representatives will help determine how your concern should be handled — as a grievance, a coverage determination, or an appeal.

A grievance is a type of complaint about our plan or one of our Kaiser Permanente or affiliated providers or pharmacies that concerns the quality of your care. It does not involve coverage or payment disputes.

A coverage determination is an initial decision we make about whether a drug prescribed for you is covered by us and the amount you are required to pay.

An appeal can be made if you disagree with a decision to deny a request for Part D drugs, or a decision to deny payment for drugs.

We will respond to your concerns as quickly as possible through our coverage determination and appeals process, which is detailed below and also in your Annual Notice of Changes/Evidence of Coverage.

Coverage determinations

A coverage determination may be requested by you, your appointed representative, your Kaiser Permanente or affiliated provider, or other prescriber.

If you name someone to act on your behalf as your appointed representative, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative♦.

To request an exception, you, your appointed representative, your Kaiser Permanente or affiliated provider, or other prescriber may use the CMS coverage determination form♦ to provide substantiation supporting your request. Use of this form is not required as long as the information from the form is included in the request.

A coverage determination may be requested in the following ways:

by calling Member Services at 1-800-232-4404 (toll free) or TTY 711, 8 a.m. to 8 p.m., 7 days a week.

by faxing the completed form or information to the Member Services fax line at (404) 364-4939

by delivering the completed form or information or making a request in person at your local Member Services department at a Kaiser Permanente location.

A decision about whether we will cover a drug can be either a standard decision, which is made within 72 hours after receipt of your physician's supporting statement (only for drugs which you have not yet received), or an expedited (fast) decision, which is made within 24 hours. Note: The decision time frame does not begin until our plan receives the completed and signed statement.

You can ask for an expedited decision only if your Kaiser Permanente or affiliated provider states that waiting for a standard decision could seriously harm your life, health, or ability to regain maximum function. Expedited decisions apply only if you are requesting coverage for drugs that you have not received.

You may also submit reimbursement requests for Part D drugs purchased at an out-of-network pharmacy or if you believe you were incorrectly charged through our coverage determination process. We will notify you of our decision within 14 calendar days of receipt of your request. If we approve your request, payment will be made within 14 calendar days as well.

If the request for an expedited review is made by or supported by your prescribing Kaiser Permanente or affiliated provider, we will automatically follow the fast time frames. If you make the request for an expedited review yourself and we do not grant it, we will automatically transfer your request to the standard 72-hour time frame.

If we deny your expedited review by phone, you can request a 24-hour expedited grievance at that time if you disagree with our decision. Otherwise, we will send you a letter within 3 calendar days after we call you with information on how to file the expedited grievance. It also will explain that we will automatically give you an expedited decision if you get the prescribing Kaiser Permanente or affiliated provider's support for an expedited review.

If you or your prescribing Kaiser Permanente or affiliated provider has any questions about this process or want to check on the status of a request, please call Member Services.

Appeals

If you disagree with our coverage determination about your drug, you have the right to file an appeal, also called a plan "redetermination." You must request an appeal within 60 days from the date of our denial notice, unless you show good cause for a delay past 60 days.

You must file your request for a standard appeal in writing at the address shown on your denial notice. You have the right to give us new information to support your appeal by telephone or fax, in writing, or by hand-delivering it to your local Member Services department.

Note: Delivery of information by hand does not mean our plan provides in-person hearings for enrollees.

An appeal may be filed either as a written standard request or as an expedited (fast) request, which may be filed in writing or by contacting us by telephone or fax at the numbers provided in your coverage determination denial letter.

You also may complete the coverage redetermination form♦ and fax it to the Part D Unit fax line at (404) 364-4939 or mail it to the following address:

A standard appeal decision will be made within 7 calendar days. If our decision is fully in your favor, we must authorize the service within 7 days and/or make the payment within 30 calendar days after we receive your appeal.

If waiting for a standard decision could seriously harm your life, health, or ability to regain maximum function, you or your prescribing Kaiser Permanente or affiliated provider may request an expedited appeal for a decision within 72 hours. The fast appeal process does not apply to denied claims for payment.

Whom to contact for inquiries

If you have questions or concerns about services or the care you receive, problems with a particular Medicare Part D prescription drug, or appointing a representative, if necessary, to handle your coverage determination or appeal, you may submit a complaint online or call Member Services at 1-800-232-4404 (toll free) or TTY 711, seven days a week, from 8 a.m. to 8 p.m., or visit the Member Services department at your local Kaiser Permanente facility. You also may use the online Medicare Complaint Form† to transmit a complaint directly to Medicare.

Aggregate number of grievances, appeals, and exceptions

You may obtain a summary of information about the appeals and grievances that plan members have filed with Kaiser Permanente. To get this information, please call our Member Services department.

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Your options upon disenrollment

If you leave Kaiser Permanente Senior Advantage, you have other options for obtaining prescription drug coverage.

Medicare Prescription Drug Plan (PDP). This plan adds prescription drug benefits to your Original Medicare coverage. To enroll in a Prescription Drug Plan in your area, you must be entitled to Medicare benefits under Part A and/or currently enrolled in Part B, and reside in the service area of the Prescription Drug Plan.

Medicare Advantage Prescription Drug Plan (MA-PD). You can join another Medicare Advantage plan with prescription drug coverage if it is available in your area, accepting new members, and if you meet the plan’s eligibility requirements.

If you choose to join another Medicare Advantage plan that offers prescription drug coverage, then you must obtain your Medicare prescription drug coverage through that Medicare Advantage plan.

Disenrollment from a Medicare health plan is subject to CMS enrollment rules. For more information about disenrolling from our plan, please review Chapter 10 in your Annual Notice of Changes/Evidence of Coverage.

For more information about your rights and responsibilities, please review Chapters 8 and 10 in your Annual Notice of Changes/Evidence of Coverage. If you have questions about joining a Medicare Advantage plan in your area, contact 1-800-MEDICARE (1-800-633-4227) (toll free), or 1-877-486-2048 (toll-free TTY for the hearing/speech impaired), 24 hours a day, 7 days a week. Or visit the Medicare website†.

Note: If you go without a Medicare drug plan or other creditable prescription drug coverage† for a continuous period of 63 days or more, you may have to pay a late enrollment penalty when you enroll in a Medicare Part D plan later.

We have interpreters available, at no cost, for more than a dozen languages. Learn more about our multi-language interpreter services♦ that are just a toll-free phone call away.

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Contact information

Prospective members may call our licensed sales specialists for more information about Senior Advantage (HMO) at 1-877-269-9821 or TTY 711, seven days a week, 8 a.m. to 8 p.m.

Current members requesting health plan benefit information or who have questions about Medicare prescription drug expenses or who need materials in an alternate format or language may call Member Services at 1-800-232-4404 or TTY 711, seven days a week, 8 a.m. to 8 p.m.

For questions about your medications, please consult your Kaiser Permanente or affiliated provider, or contact your local Kaiser Permanente or affiliated pharmacy at the number listed on your prescription label.

For more information about Medicare prescription drug coverage, call 1-800-MEDICARE (1-800-633-4227) (toll free) or 1-877-486-2048 (toll-free TTY for the hearing/speech impaired), 24 hours a day, 7 days a week. Or visit the Medicare website†.

Benefits, formulary, pharmacy network, provider network, premium, and copayments/co-insurance may change on January 1 of each year.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply.

You must reside in the Kaiser Permanente Medicare health plan service area in which you enroll.

Anyone who has Medicaid and Medicare Parts A and B, including some people under the age of 65 with disabilities, may apply. Premiums, copays, coinsurance/cost sharing, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

The following information describes the advantages of Kaiser Permanente so you can choose the Medicare health plan that's right for you.

For a healthier, more vibrant you

Add dental, hearing, and vision benefits

Only $20 a month added to your Senior Advantage premium gets you dental, hearing, and vision benefits, all provided by Kaiser Permanente and its health care partners.

When you can enroll

You can enroll in Advantage Plus at the same time or after you enroll in a Kaiser Permanente Senior Advantage (HMO) plan.

If you are enrolling in Senior Advantage either as a new member or because you have moved to a different Kaiser Permanente service area, you may add Advantage Plus within 30 days of your enrollment. Coverage is effective the first day of the month following the date we receive your completed enrollment form.

If you are already a Senior Advantage member, you may add Advantage Plus during the annual election period October 15 – December 7 for coverage to become effective on January 1, 2015. If you don't enroll during the annual election period, you have until March 31, 2015 to enroll. Coverage is effective the first day of the month following the date we receive your completed enrollment form.

Get started today

To learn more about the Advantage Plus benefits, download the Advantage Plus brochure (coming soon).

The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply.

You must be a Kaiser Permanente Senior Advantage individual plan member to apply, and you must continue to pay applicable Senior Advantage and Medicare Part B premiums and any other applicable Medicare premium(s), if not otherwise paid by Medicaid or another third party.

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♦You will need the free Adobe Acrobat Reader† to read this file.†Kaiser Permanente is not responsible for the content or policies of external Internet sites.

NCQA, Leapfrog, and MedicareWebWatch awards were not given by Medicare. Official CMS Star Ratings can be found at medicare.gov†.

You must reside in the Kaiser Permanente Medicare health plan service area in which you enroll.

In California, Hawaii, Oregon, Washington, Colorado and Georgia, Kaiser Permanente is an HMO plan with a Medicare contract. In Virginia, Maryland, and the District of Columbia, Kaiser Permanente is a Cost plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal.

At sales meetings, a sales person will be present with information and applications. For accommodation of persons with special needs at sales meetings, call 1-877-220-3956 (toll free) or TTY 711. Calling this number will direct you to a licensed sales specialist.

†Kaiser Permanente is not responsible for the content or policies of external Internet sites.